| NPI | 1023387339 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX 44413) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: TX 43084) |
| Enumeration Date | 2011-12-16 |
| Last Update Date | 2017-10-18 |